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Bernadette Sreter K, Pavlović D, Tomić M, Šenjug P, Galešić Ljubanović D. PULMONARY HEMORRHAGE AND CRESCENTIC GLOMERULONEPHRITIS IN A PATIENT WITH SEROPOSITIVE ANTI-GLOMERULAR BASEMENT MEMBRANE DISEASE AND ANTI-NEUTROPHIL CYTOPLASMIC ANTIBODIES. Acta Clin Croat 2022; 61:528-533. [PMID: 37492353 PMCID: PMC10364110 DOI: 10.20471/acc.2022.61.03.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 08/29/2017] [Indexed: 07/27/2023] Open
Abstract
Anti-glomerular basement membrane (anti-GBM) disease is an acute and life-threatening systemic autoimmune disorder. The coexistence of circulating anti-neutrophil cytoplasmic antibodies (ANCA) and anti-GBM disease, the so-called double-positive disease (DPD), is exceptionally rare. We report a unique case of DPD manifesting as pulmonary-renal syndrome (PRS) in a 46-year-old woman who first presented with clinical and radiological suspicion of pneumonia. Chest computed tomography scan later revealed bilateral alveolar hemorrhage. Kidney biopsy showed necrotizing crescentic (100% glomeruli) glomerulonephritis. On immunofluorescence microscopy, glomeruli were global linear positive for IgG, confirming anti-GBM disease. Double positivity was detected for circulating anti-myeloperoxidase ANCA (p-ANCA) and anti-GBM antibodies. Acute renal failure evolved rapidly. Therapeutic plasma exchange (TPE) and hemodialysis (HD) were initiated early in combination with intravenous pulse corticosteroid therapy followed by oral methylprednisolone and cyclophosphamide. Pulmonary hemorrhage resolved, but renal function could not be preserved. The patient remains HD dependent. This case report highlights that pulmonary symptomatology may be the leading clinical presentation of PRS, with initially normal renal function at DPD onset. Early recognition and diagnosis are therefore crucial to timely clinical intervention. The role of prompt kidney biopsy and initiation of TPE and HD in PRS must not be underestimated.
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Affiliation(s)
- Katherina Bernadette Sreter
- Department of Clinical Immunology, Pulmonology and Rheumatology, Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Draško Pavlović
- Department of Nephrology and Dialysis, Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia, and University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Monika Tomić
- Department of Internal Medicine, University Hospital Mostar, Mostar, Bosnia and Herzegovina, and University of Mostar, School of Medicine, Mostar, Bosnia and Herzegovina
| | - Petar Šenjug
- Department of Pathology, University Hospital Dubrava, Zagreb, Croatia
| | - Danica Galešić Ljubanović
- Department of Pathology, University Hospital Dubrava, Zagreb, Croatia
- Department of Pathology, University of Zagreb, School of Medicine, Zagreb, Croatia
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Dowsett T, Oni L. Anti-glomerular basement membrane disease in children: a brief overview. Pediatr Nephrol 2022; 37:1713-1719. [PMID: 34767075 PMCID: PMC8586640 DOI: 10.1007/s00467-021-05333-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 01/04/2023]
Abstract
Anti-glomerular basement membrane disease (Anti-GBM), previously known as Goodpasture syndrome, is an extremely rare cause of rapidly progressive glomerulonephritis and chronic kidney disease stage 5 (CKD5) in children. It is associated with acute pulmonary haemorrhage and it has a poor prognosis. It is classified as an autoimmune, small-vessel vasculitis caused by autoantibody formation against the alpha-3 chain in type IV collagen found in the glomerular basement membrane. Evidence of anti-GBM antibodies in serum or histologically are required for diagnosis. Treatment in children is based on very limited adult data and often involves the use of acute apheresis to rapidly remove circulating factors coupled with intensive immunosuppression such as cyclophosphamide and intravenous corticosteroids. There is also an emerging role for the use of biologic agents such as B cell depletion. The evidence base in children with anti-GBM disease is extremely limited. Multi-centre international collaboration is required to provide insight into this disease, better describe its prognosis and work towards improving outcomes. This review article summarises the key features of this disease in children, highlights treatment options and considers areas of unmet need.
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Affiliation(s)
- Thomas Dowsett
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Louise Oni
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust Hospital, Eaton Road, Liverpool, L12 2AP, UK.
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Eaton Road, Liverpool, L12 2AP, UK.
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Philip R, Dumont A, Martin Silva N, de Boysson H, Aouba A, Deshayes S. ANCA and anti-glomerular basement membrane double-positive patients: A systematic review of the literature. Autoimmun Rev 2021; 20:102885. [PMID: 34242834 DOI: 10.1016/j.autrev.2021.102885] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Double-positive patients (DPP) exhibiting anti-glomerular basement membrane (GBM) and anti-neutrophil cytoplasmic antibodies (ANCAs) belong to an entity that is newly and poorly described, mainly in short series. We aimed to better characterize the epidemiological features, clinical presentation and therapeutic outcomes of these patients through a systematic review. METHODS We performed a systematic review of English-, German-, Spanish- and French-written publications from February 1987 to March 2020 reporting cases of DPP using the following databases: PubMed, Scielo, ScienceDirect, Google Scholar, The Cochrane Library, Open Grey, The Grey Literature Report, Clinicaltrials.gov and International Clinical Trial Registry Platform of the World Health Organization. RESULTS In total, 538 DPP were identified from 90 articles. Their clinical presentations were often severe, and the majority exhibited acute kidney failure (91.8%) with a median initial serum creatinine level of 873 μmol/L; 50.7% had alveolar haemorrhage. Other manifestations were present in 30.3% of DPP, mainly ear, nose, throat and articular manifestations. ANCAs were predominantly directed against MPO (n = 377/523; 72.1%) compared to PR3 (n = 107/523; 20.5%), with rare cases of triple positivity (n = 15/538; 2.9%). Although most patients received initial immunosuppressive therapy (n = 285/317; 89.9%), the one-year overall, renal and relapse-free survival rates were 64.8%, 38.7% and 71.1%, respectively. CONCLUSION DPP are associated with the characteristics of two eponymous vasculitis types, responsible for a poor overall and renal prognosis. Thus, simultaneous testing of both antibodies and systematic renal biopsy should be recommended in every patient with rapidly progressive glomerulonephritis to recognize this difficult-to-treat and rare disease.
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Affiliation(s)
- Rémi Philip
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France
| | - Anael Dumont
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000 Caen, France
| | - Nicolas Martin Silva
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France
| | - Hubert de Boysson
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000 Caen, France
| | - Achille Aouba
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000 Caen, France.
| | - Samuel Deshayes
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000 Caen, France
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Helander L, Hanna M, Annen K. Pediatric double positive anti-glomerular basement membrane antibody and anti-neutrophil cytoplasmic antibody glomerulonephritis-A case report with review of literature. J Clin Apher 2021; 36:505-510. [PMID: 33629780 DOI: 10.1002/jca.21886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 12/02/2020] [Accepted: 01/24/2021] [Indexed: 12/12/2022]
Abstract
Anti-glomerular basement membrane (GBM) disease is a rarely described entity in the pediatric population, especially in those less than 3 years old. Even rarer, is double seropositive disease, consisting of anti-GBM antibody plus anti-neutrophil cytoplasmic antibodies. Both single and double antibody positive diseases are characterized by rapidly progressive glomerulonephritis, often without pulmonary involvement in the pediatric population. We report the case of a 2-year-old child with double seropositive anti-GBM disease, the youngest in the current literature, along with the role of therapeutic plasma exchange and rituximab in disease treatment.
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Affiliation(s)
- Louise Helander
- ClinImmune Labs, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Melisha Hanna
- School of Medicine, University of Colorado, Aurora, Colorado, USA.,Children's Hospital Colorado, Aurora, Colorado, USA
| | - Kyle Annen
- Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Pathology, University of Colorado, Aurora, Colorado, USA
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Dorval G, Lion M, Guérin S, Krid S, Galmiche-Rolland L, Salomon R, Boyer O. Immunoadsorption in Anti-GBM Glomerulonephritis: Case Report in a Child and Literature Review. Pediatrics 2017; 140:peds.2016-1733. [PMID: 29054981 DOI: 10.1542/peds.2016-1733] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2017] [Indexed: 11/24/2022] Open
Abstract
Antiglomerular basement membrane glomerulonephritis (anti-GBM GN) is a rare autoimmune disease that is characterized by rapidly progressive glomerulonephritis that may be associated with pulmonary hemorrhage. Anti-GBM GN is caused by autoantibodies (classically type G immunoglobulin) directed against the α3 subunit of type IV collagen. Without any appropriate treatment, the disease is generally fulminant, and patient and kidney survival is poor. The current guidelines recommend the use of plasma exchanges and immunosuppressive drugs. Immunoadsorption (IA) can remove pathogenic IgGs from the circulation and do not require plasma infusions, contrary to plasma exchanges. IA has seldom been used in adult patients with good tolerance and efficiency. We report herein the first pediatric case successfully treated with IA combined with immunosuppressive drugs in a 7-year-old girl who presented acute kidney injury (estimated glomerular filtration rate 38 mL/minute/1.73 m2). A kidney biopsy revealed numerous >80% glomerular crescents and linear IgG deposits along the glomerular basement membrane. Ten IA sessions led to rapid and sustained clearance of autoantibodies and improvement of kidney function until 21 months after onset (glomerular filtration rate 87 mL/minute/1.73 m2). No adverse effect was noted. This report adds to the growing body of evidence suggesting IA as a therapeutic alternative to plasma exchanges in anti-GBM GN. The other 27 published pediatric cases of anti-GBM GN are reviewed.
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Affiliation(s)
- Guillaume Dorval
- Department of Pediatric Nephrology, MARHEA - Necker Hospital - APHP, Imagine Institute, Paris Descartes University, Paris, France; and
| | - Mathilde Lion
- Department of Pediatric Nephrology, MARHEA - Necker Hospital - APHP, Imagine Institute, Paris Descartes University, Paris, France; and
| | | | - Saoussen Krid
- Department of Pediatric Nephrology, MARHEA - Necker Hospital - APHP, Imagine Institute, Paris Descartes University, Paris, France; and
| | | | - Rémi Salomon
- Department of Pediatric Nephrology, MARHEA - Necker Hospital - APHP, Imagine Institute, Paris Descartes University, Paris, France; and
| | - Olivia Boyer
- Department of Pediatric Nephrology, MARHEA - Necker Hospital - APHP, Imagine Institute, Paris Descartes University, Paris, France; and
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Kataoka G, Asano R, Sato A, Tatsuishi W, Nakano K. Aortic valve replacement in a patient with MPO-ANCA-positive Goodpasture disease. Surg Case Rep 2016; 2:100. [PMID: 27654701 PMCID: PMC5031572 DOI: 10.1186/s40792-016-0230-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/15/2016] [Indexed: 11/17/2022] Open
Abstract
Goodpasture disease (GD) is a rare autoimmune disorder characterized by the development of pathologic autoantibodies against both glomerular and alveolar basal membranes. Approximately one third of the patients with GD are also positive for anti-neutrophil cytoplasmic antibody (ANCA). In this case report, a 74-year-old woman was diagnosed as having myeloperoxidase (MPO)-ANCA-positive GD with severe aortic valve stenosis (AS). She underwent immunosuppressive therapy and plasmapheresis that led to GD remission. Whether a cardiac surgery affects a MPO-ANCA-positive GD in remission is unknown. We reported the outcomes after aortic valve replacement for severe AS in a patient with MPO-ANCA-positive GD.
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Affiliation(s)
- Go Kataoka
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa-ku, 116-8567, Tokyo, Japan.
| | - Ryota Asano
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa-ku, 116-8567, Tokyo, Japan
| | - Atsuhiko Sato
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa-ku, 116-8567, Tokyo, Japan
| | - Wataru Tatsuishi
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa-ku, 116-8567, Tokyo, Japan
| | - Kiyoharu Nakano
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa-ku, 116-8567, Tokyo, Japan
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Chin CIC, Kohn SL, Keens TG, Margetis MF, Kato RM. A physician survey reveals differences in management of idiopathic pulmonary hemosiderosis. Orphanet J Rare Dis 2015; 10:98. [PMID: 26289251 PMCID: PMC4545926 DOI: 10.1186/s13023-015-0319-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/09/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Idiopathic pulmonary hemosiderosis (IPH) is a rare disorder of unknown etiology characterized by chronic pulmonary hemorrhage and presents with a triad of anemia, hemoptysis and pulmonary infiltrates. IPH is a diagnosis of exclusion with a variable and disparate clinical course. Despite existing therapies, few children achieve full remission while others have recurrent hemorrhage, progressive lung damage, and premature death. METHODS We surveyed physicians who care for patients with IPH via a web-based survey to assess the most common practices. 88 providers responded, caring for 274 IPH patients from five continents. RESULTS 63.3 % of respondents had patients that were initially misdiagnosed with anemia (60.0 %) or gastrointestinal bleed (18.2 %). Respondents varied in diagnostic tools used for evaluation. The key difference was in the use of lung biopsy (51.9 %) for diagnosis. Common medications respondents used for treatment at initial presentation and chronic maintenance therapy were corticosteroids (98.7 and 84.0 %, initial and chronic therapy respectively), hydroxychloroquine (33.3 and 64.0 %), azathioprine (8.0 and 37.3 %), and cyclophosphamide (4.0 and 16.0 %). There was agreement on the use of corticosteroids for exacerbation amongst all respondents. Reported deaths before adulthood occurred in 7.3 % of patients. We conclude that there were common features and specific variations in physician management of IPH. Respondents were divided on whether to perform lung biopsy for diagnosis. CONCLUSION Despite the availability of various immunomodulators, corticosteroids remained the primary therapy. We speculate that the standardization of care for diffuse alveolar hemorrhage will improve patient outcomes.
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Affiliation(s)
- Chana I C Chin
- Division of Pulmonology, Children's Hospital Los Angeles, Los Angeles, California.
| | | | - Thomas G Keens
- Division of Pulmonology, Children's Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Monique F Margetis
- Division of Pulmonology, Children's Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Roberta M Kato
- Division of Pulmonology, Children's Hospital Los Angeles, Los Angeles, California.
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California.
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Xie LJ, Cui Z, Jia XY, Chen Z, Liu XR, Zhao MH. Coexistence of Anti-Glomerular Basement Membrane Antibodies and Anti-Neutrophil Cytoplasmic Antibodies in a Child With Human Leukocyte Antigen Susceptibility and Detailed Antibody Description: A Case Report. Medicine (Baltimore) 2015. [PMID: 26200622 PMCID: PMC4603008 DOI: 10.1097/md.0000000000001179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Anti-glomerular basement membrane (anti-GBM) disease and anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis both could cause rapidly progressive glomerulonephritis. The coexistence of ANCAs and anti-GBM antibodies was known as "double positive," which was extremely rare in children. We report a pediatric case with coexistence of ANCAs and anti-GBM antibodies. A 6-year-old girl presented with acute renal failure, hematuria, proteinuria, and oliguria. She was double positive of ANCAs specific to myeloperoxidase, and anti-GBM antibodies. Kidney biopsy confirmed linear immunoglobulin (Ig)G deposit along GBM and 100% of crescent formation in glomeruli; among them 83.3% were cellular crescents. Human leukocyte antigen (HLA) gene typing showed DRB1*1501, an allele strongly associated with anti-GBM disease, and DRB1*0405, an independent risk factor for renal failure in patients with ANCA-associated vasculitis. The titer of anti-GBM antibodies was 1:800, and the predominant IgG subclass was IgG1, which was closely related with severe kidney injury and worse outcome. The target antigen of anti-GBM antibodies was restricted on the noncollagen domain 1 of the α3 chain of type IV collagen (α3[IV]NC1), with recognitions to both epitopes, EA (α317-31) and EB (α3127-141). This is the first reported pediatric case with coexistence of ANCAs and anti-GBM antibodies, in which the HLA typing and immunologic characters of autoantibodies were identified. The findings on this early-onset patient are meaningful for understanding the mechanisms of both anti-GBM disease and ANCA-associated vasculitis.
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Affiliation(s)
- Li-Jun Xie
- From the Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China (L-jX, ZC, X-yJ, M-hZ); Department of Nephrology, Beijing Children's Hospital affiliated to Capital Medical University (ZC, X-rL); Renal Division, Department of Medicine, First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China (L-jX); and Peking-Tsinghua Center for Life Sciences, Beijing, PR China (M-hZ)
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Goodpasture's syndrome: A clinical update. Autoimmun Rev 2015; 14:246-53. [DOI: 10.1016/j.autrev.2014.11.006] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 11/09/2014] [Indexed: 11/22/2022]
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Ngobia A, Alsaied T, Unaka NI. Henoch-Schönlein purpura with hemoptysis: is it pneumonia or something else? Hosp Pediatr 2014; 4:316-20. [PMID: 25318115 DOI: 10.1542/hpeds.2014-0035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Anne Ngobia
- Pediatric Residency Training Program, Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Tarek Alsaied
- Pediatric Residency Training Program, Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ndidi I Unaka
- Pediatric Residency Training Program, Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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